Lord Cullen's report describes how, at 8.06am, on October 5 1999, Michael Hodder, driving a three-carriage Thames train bound for Bedwyn in Wiltshire left Paddington station with 147 passengers on board. Two minutes later, as the train sped along at 41mph, Mr Hodder went through the now notorious signal, SN109, failing to see, through a combination of sunlight and its obscured position, that it was on red for danger.

At the same time, a First Great Western high speed train from Cheltenham was hurtling towards Paddington at up to 100mph carrying 421 passengers. Spotting the imminent crash, a signaller at the control centre in Slough switched signal SN120 to red, but the high speed train passed through it. Both drivers applied their brakes but 33 seconds after the Thames train passed SN109, the two trains smashed into one another at a combined 130mph, killing 31 people.

The crash

As the high speed train hit the turbo train, the smaller train's cab and left hand side were destroyed, and its fuel tank began to leak diesel. The turbo's front and middle carriages shunted into each other, while the end of the high speed train's power car pushed into coach H, which then rode up above it. Fires began almost immediately, with the most horrific occurring in coach H, where witnesses described a fireball coming through it from the rear. Of the seven deaths on the high speed train, all bar the driver were in this carriage, while many others suffered severe burns.

The report found there was no organised evacuation after the crash. Passengers on the high speed train had difficulty in opening external doors, particularly on coaches that had tilted over, and finding hammers to break windows. On the turbo train, passengers were unable to open internal doors, and the report notes it was "fortunate" those in the rear carriage were able to escape through the rear cab. Thames trains had removed their emergency hammers - a move that "compromised the safety of passengers."

Mr Hodder's actions

The inquiry heard that drivers had experienced "persistent and serious difficulty" in seeing signals between Paddington and Ladbroke Grove, and that signal SN109, described by one expert witness as "a black spot", had been passed at red on eight occasions since August 1993.

Michael Hodder, with 250 hours' driver instruction, had "slender experience" and had only qualified 13 days before. The report found there were "significant shortcomings" in his training: his instructor did not recognise it was part of his job to teach routes in and out of Paddington and Mr Hodder was not taught to pay particular attention to signals, such as SN109, which had been regularly passed at danger. Such incidents were known within the industry as "spads".

Lord Cullen refers to the poor siting of SN109 and the effect of bright sunlight at a low angle when Mr Hodder passed it. While he had eight seconds to see the signal, its unusual shape - a "reverse L" - made it more difficult to spot and might well have misled him into thinking he could continue. "The fact that he had not been instructed that signal 109 was a multi-spad signal increased the risk of his making, and not correcting, a mistake."

The actions of the signallers

The report condemned the "slack and complacent regime" for signallers at the integrated electronic control centre at Slough. It concluded that, if the manage ment had applied the lessons of past spads, "it may well be the case that the signaller would have been able to send the emergency message in time to enable the turbo to be brought to a halt ... before ... it fouled the path of the HST".

In the event, the signaller, David Allen, took up to 9.25 seconds to send an emergency stop message to Mr Hodder, and it is unclear if he received it before the trains crashed. Although there had been 46 spads in the area covered by the centre, from 1993-99, there was "no training in the management of them, either by way of rehearsal or checking responses".

While a signaller noticed that the Thames train had gone through SN109, he failed to take action for a period of time - disputed because of the "inconsistent" and unreliable evidence of his and his colleagues' evidence - because he assumed it would stop within 200 yards.

Railtrack and the infrastructure

The report's fiercest criticism was reserved for Railtrack, which it condemned for its "lamentable failure" in responding to recommendations of inquiries into two serious spads in the area, and its "institutional paralysis".

It found that, since 1993, train crews had warned of the "inadequate sighting of certain signals", including SN109, but there was an "inadequate overall consideration of these difficulties" and an "inadequate reconsideration" of the signalling scheme. A combination of "incompetent management and inadequate procedures" meant that signal sighting committees persistently failed to meet, while, despite a number of measures being mooted, "very little" had been achieved to improve safety. The impression given was "senior management were content to wait till proposals had been put up to them, and failed to give and maintain the lead in seeking solutions", Lord Cullen said.

Railtrack were sent three written warnings before the crash by Alison Forster, operations and safety director for First Great Western, which were ignored. In one, she wrote asking "as a matter of urgency what action you intend to take"; in another, in December 1998, she warned: "It is clear from all the spads in the Paddington area that there is a serious problem with drivers misreading signals." The report highlighted the "damning critique" of one Railtrack director, a Mr McNaughton, who told the inquiry that the Great Western zone he managed had been "declining for at least a decade", while "the culture of the place had gone seriously adrift over the years". In contrast, former Railtrack chief executive Gerald Corbett's comment, a year before the crash, that Paddington was the "best protected" station in the UK was, in Lord Cullen's view, "not only ill-considered, but ... demonstrated either a degree of complacency on the part of senior management or a desire to encourage and undeserved confidence in what Railtrack had actually achieved".

Thames Trains and automatic train protection

Lord Cullen found that it was "highly probable" that the crash would not have happened if the turbo train had been fit ted with automatic train protection, yet concluded that it was "reasonable" for Thames Trains to have installed the less-expensive train protection warning system.

The report criticised the company, however, for a "safety culture in regard to training that was slack and less than adequate". Driver standards managers conducted classes as each thought best, and there were gaps in instruction - most obviously in Mr Hodder's instructor, named only as Adams, not recognising it was part of his job to teach route knowledge.

While the company - which had seen spads occur at twice the industry rate - had gone some way to improve its safety record, "more could and should have been done to organise driver training and management in a systematic manner". The problems were so pronounced, Adams even told one trainee: "This is Paddington, and sort of make the best of it really."

Helen Mitchell, 38, university lecturer, travelling in coach E of the First Great Western train, from Stroud:

"I was meant to be on that train - I caught the guard's eye as the doors were closing and he reopened them for me - and my experience still affects me. I remember this tremendous bang, and after about 10 seconds, flames coming up the carriage.

"I managed to get out, stumbled across the tracks and fell over a severed arm. A woman's arm, with pink nail varnish on, an engagement ring and a wedding ring.

"I still suffer from flashbacks and nightmares, I can't work, and I have a heightened sense of impending danger: you see tragedy where other people wouldn't and that can put a strain on your relationships.

"I'm very relieved by the report. The anger comes and goes at different times, but I do feel a jaw-dropping incredulity about things - like the fact the signal man presumed the train would stop.

"But I don't think blame is the answer: the whole reason this happened is because of a blame culture and if we feel like that, we're as bad as them. We've got to move on."

Andrea Bryce, 25, travel coordinator, from Edinburgh, who was travelling to a training course, in the rear carriage of the Thames Turbo train.

"I don't remember much after the crash, except for being covered in diesel and being terrified of the fire and elec tric cables. I had to give up my new job and move back to Edinburgh - I kept telling myself to stick it out for another month, but I couldn't cope with being in London any longer. I wouldn't go back on a train. I have a car now and I drive myself around. I don't fancy being a passenger of any description: never again - and I even get anxious when someone I know has to go on a train."

Colin Paton, 56, a father-of-five from Bristol, was the guard on the First Great Western train and alerted the emergency services by using a phone in the drivers' cab. He was made redundant last week after being on sick leave since the crash.

"Until safety is taken out of Railtrack's hands, the recommendations will not be carried out soon enough: We need an independent body that can be proactive rather than reactive. I have had a constant headache since the accident and last week saw a specialist who put injections into the back of my head to try and relieve the pain. I have had bad dreams every night since the crash and they are always very aggressive. I did try to go back on a train but broke down in tears. I couldn't cope."

Pam Warren, 34, a former financial adviser from Whitchurch, Oxfordshire, who spent 18 months in a mask following horrific burns sustained as she travelled in First Great Western's coach H.

"We have been told by the government and the rail industry that they were waiting for Lord Cullen's report. Well it's out now. They had 20 months to ponder on what it might say and I don't think anything in it will come as much of a surprise. We want them to get acting straight away ... get on with it now.

"I can't work any more, and I have a psychologist and psychiatrist who tell me it might be up to five years before I can put this behind me. I get about five flashbacks a day and, despite taking sleeping tablets, have four or five nightmares a night. The flashbacks are worse, and they start with me being back on the train and the fireball coming. I feel a great sense of relief and some pride, and I think we have to be optimistic for the future. There would be no point in us fighting on otherwise."

What now?

The report sets out 88 recommendations including:

 Railtrack should examine track layout up to two miles from Paddington to check safety of train speeds and traffic arrangements

 Signallers and drivers should be taught about the demands of each others' jobs

 Thames Trains should assess drivers more frequently

 When signals are positioned there must be "explicit consideration" to how well they can be seen

 There should be no presumption that driver error is the sole or principal cause of spads (signals passed at danger) or that the infrastructure is only a contributory factor

 Signallers' instructions for responding to a spad should be clarified

 A feasibility study should be carried out to see if all signals in an area where a spad has occurred can be turned to red if there is "significant" danger of collision

 There should be direct radio communications between trains and signallers and - if a risk assessment permits this - an audible warning should automatically sound in the cab when a train passes a signal at danger

 There should be an inquiry into the practicalities of using smaller fuel tanks to minimise the risk of fire

 There should be a thorough review of the adequacy of the number of emergency hammers in train carriages